Complement and coagulation cascade cross-talk in endometriosis and the potential of Janus Kinase inhibitors-a network meta-analysis

Abstract

Background: Molecular events that drive endometriosis (EM) and cause accompanying immune deregulation remain elusive. Our purpose was to identify key pathways involved in lesion formation across diverse populations and to detect transcriptomic changes in eutopic endometrium that accompany EM.

Methods: We searched Gene Expression Omnibus and ArrayExpress and performed differential gene expression analysis and a network meta-analysis on nine qualifying datasets. Those contained transcriptomic data on 114 ectopic endometrium samples (EL), 138 eutopic endometrium samples from women with endometriosis (EEM), and 79 eutopic endometrium samples from women without endometriosis (EH). Gene ontology and enrichment analysis were performed in DAVID, Metascape, and Cytoscape, and drug repurposing was done in CMap.

Results: EEM compared to EH upregulated CCL21 and downregulated BIRC3, CEL, and LEFTY1 genes (|log₂FC| > 0.5, p < 0.05). EL showed increased expression of complement and serpin genes (EL vs. EEM: C7, logFC = 3.38, p < 0.0001; C3, logFC = 2.40, p < 0.0001; SERPINE1, logFC = 1.02, p < 0.05; SERPINE2, logFC = 1.54, p < 0.001) and mast cell markers (EL vs. EEM: CPA3, logFC = 1.54, p < 0.0001; KIT, logFC = 0.74, p < 0.001). Functional enrichment analysis highlighted complement and coagulation, inflammation, angiogenesis, and extracellular matrix remodeling as drivers of endometriosis. Pharmacogenomic analysis indicated Janus kinase (JAK), cyclin-dependent kinase (CDK), and topoisomerase inhibitors as therapy targets.

Conclusion: Our results suggest an interplay between complement and coagulation, mast cells, extracellular matrix remodeling, and the JAK/STAT3 pathway in endometriosis. We underscore the significance of complement C3 and propose JAK inhibitors as therapy candidates. Detected expression differences between EEM and EH are important for the development of diagnosis via endometrial biopsy.

Keywords: Janus kinase (JAK) inhibitors; complement and coagulation; endometriosis; eutopic and ectopic endometrium; mast cells; network meta-analysis.

Figure 1

Flow diagram showing the selection process of databases retrieved from the Gene Expression Omnibus search for transcriptomic data comparing eutopic and ectopic endometrial tissue. All datasets from ArrayExpress were also deposited in Gene Expression Omnibus thus they were not further considered in the selection process. Created in https://BioRender.com.

Figure 2

Differentially expressed genes identified by network meta-analysis. Volcano plots showing differentially expressed genes for the following comparisons (A) endometriotic lesions versus endometrium from women with endometriosis, (B) endometriotic lesions versus endometrium from women without endometriosis, (C) endometrium from women with and without endometriosis. For graphs A to C, red points signify genes with logFC less than −0.5 or more than 0.5 and p-value less than 0.05, blue points signifiy genes with logFC belonging to −0.5 to 0.5 range and p-value less than 0.05, green points signify genes with logFC less than −0.5 or more than 0.5 and p-value more than 0.05 and gray dots signify genes with with logFC belonging to −0.5 to 0.5 range and p-value more than 0.05. Genes with p-values < 1 × 10⁻⁶ and log2FC>|2| (A, B) and p-values < 0.05 and log2FC>|0.5| (C) are labeled. Heatmap with top 40 most differentially expressed genes per comparison per dataset (D). Expression pattern of differentially expressed genes per comparison type (E). EL, endometrial lesion; EEM, eutopic endometrium from women with endometriosis; EH, eutopic endometrium from women without endometriosis.

Figure 3

Enriched pathways analysis, functional clustering and computational pharmacogenomics of DEGs between endometriosis lesions and eutopic endometrium. Gene ontology analysis using DAVID (A) reveals the importance of inflammation, cell adhesion, angiogenesis and ECM remodeling. Metascape enrichment analysis (B) and relationship network of enriched terms visualised in Cytoscape (C) show key events that contribute to endometriosis development. Those include inflammatory and hormonal response and proliferation and locomotion. Functional annotation clustering reports the highest enrichment score for complement and coagulation cascade, platelet activation, DNA remodeling and integrin mediated signaling respectively (D). Top 15 drug candidates identified using a drug repurposing reference database—CMap and showing median tau value above 95. JAK, CDK, and topoisomerase inhibitors are identified as potential pharmacological targets for endometriosis therapy (E).

Figure 4

Differential gene expression across studies for selected genes from the complement and coagulation pathway for the comparison between EL versus EEM. Forest plot showing the expression of C1QA (complement C1q A chain) - (A), C3 (complement C3) - (B), C7 (complement C7) - (C), SERPINE1 (serpin family E member 1) - (D), SERPINE2 (serpin family E member 2) - (E), and SERPINA5 (serpin family A member 5) - (F). Direct and indirect comparisons from meta-analysis are presented in row number five and six. The indirect comparisons had a low impact on the combined comparison outcome due to the analyses being performed on datasets containing comparisons between EL and EEM ( Table 2 ).

Figure 5

Differential gene expression across studies for selected genes, including mast cells markers, JAK/STAT pathway, and extracellular matrix markers. Forest plot showing the expression of CPA3 (mast cell carboxypeptidase A) – (A), KIT (tyrosine-protein kinase KIT) – (B), MS4A6A (Membrane Spanning 4-Domains A6A) – (C), FCGR2B (Fc Gamma Receptor IIb) – (D), S100A10 (S100 calcium-binding protein A10) – (E), MMP-9 (Matrix metalloproteinase-9) – (F), STAT5A (Signal Transducer And Activator Of Transcription 5A) – (G), and STAT5B (Signal Transducer And Activator Of Transcription 5B) – (H). Direct and indirect comparisons from meta-analysis are presented in row number five and six.

Figure 6

Schematic representation of proposed key molecular processes contributing to lesion development. This diagram illustrates the complex interplay between the complement system, coagulation cascade, extracellular matrix remodeling, and immune signaling pathways in the context of lesion formation. Coagulation factors cleave and activate complement components C3 and C5, initiating pro-inflammatory responses. Complement factor C3 also functions to stabilize clots by protecting them from fibrinolysis. The coagulation cascade is tightly regulated by members of the serpin superfamily, which modulate extracellular matrix remodeling through the induction of matrix metalloproteinase-9 (MMP-9) expression. Complement activation further engages the JAK/STAT signaling pathway, particularly STAT5, promoting mast cell activation. Activated mast cells, in turn, influence coagulation dynamics. Pharmacologic inhibition of the JAK/STAT pathway using JAK inhibitors can suppress STAT3 signaling and reduce mast cell degranulation, thereby modulating both inflammatory and thrombotic processes. These mechanisms highlight the therapeutic potential of JAK inhibitors in the context of endometriosis. Genes names in green signify differentially expressed genes, arrows show the directional change in gene expression in endometriosis lesions compared with control endometrium. Created in BioRender.com.